1. Field of the Invention
This invention relates to new and useful improvements in breast augmentation mammoplasty and more particularly to an endoscopic approach to the operation. The invention relates generally to a surgical apparatus and technique utilizing an endotube and obturator, special instruments, and the insertion of a breast prosthesis through a tunnel from an incision remote from the breast at a point not ordinarily visible to a space behind the breast which is expanded by the prosthesis into a pocket in which it is confined.
2. Brief Description of the Prior Art
Historically, material such as paraffin, glass beads, silicone gel and a patient's own fat have been used by injection means to augment or enhance the female breast. These methods have been abandoned.
Current methods of enhancement involve such diverse means as using a flap of the patient's own tissue (skin and subcutaneous fat plus the underlying fascia and/or muscle and fascia) taken from another location on the body and transferred to the breast by microvascular anastomosis--called a free flap transfer, or transferred to the breast still attached to the muscle and fascia, with one end of the muscle remaining attached to its blood supply (which in turn keeps the skin and fat attached to it alive)--called a myocutaneous flap or a tram flap.
These methods of transfer of flaps of the patient's own tissue, however, are seldom if ever used for the cosmetic enlargement of the female breast. These methods are almost always used for reconstruction of the female breast after cancer surgery or other post surgical complications.
Current methods of enhancement for purely cosmetic purposes involve the placement of an implant device beneath each breast or beneath each pectoralis major muscle (which places the implant device beneath both the breast and its underlying pectoralis major muscle).
Historically, every method or surgical means for implantation of a device for breast enlargement involves the making of an incision on each breast (usually in the nipple area or inframammary crease area) or making an incision in each axillary area and surgically creating a pocket (or space) underneath each breast or underneath each breast and pectoralis muscle. Beneath the breast only is called subglandular and beneath the breast and muscle is called submuscular--also called submammary and submusculofacia.
In an occasional patient who had an existing scar in the midline chest or upper abdomen or who was undergoing an abdommoplasty (tummy tuck), a surgical approach was made to each breast, using that one incision and the pockets created to contain the implant devices.
In all the medical literature; surgical creation of the pocket, in the subglandular or in the submuscular location, involves two basic techniques, each technique utilizing two skin incisions (nipple, inframammary or axillary) one incision to gain access to each breast to create the pockets. The two techniques are the blunt dissection and the sharp dissection technique.
The blunt dissection technique involves gaining access to the breast through a skin incision. The surgeon then identifies the location (subglandular or submuscular) and, using a finger or other blunt surgical instrument, the breast is bluntly separated from the pectoralis muscle fascia (to create the subglandular pocket) or the pectoralis major muscle is bluntly separated from the chest wall (to create the submuscular pocket). The blunt dissection technique is usually done "blindly" not under direct vision.
The sharp dissection technique involves gaining access to the breast through a skin incision. The surgeon then uses a knife, scissors, electrocautery, or laser to dissect the subglandular or submuscular pocket. The sharp dissection technique is almost always done under direct vision.
The blunt dissection technique generally causes more bleeding and bruising, and after blunt dissection many surgeons will then use direct vision and cautery or laser to control any blood vessels that are bleeding.
Many surgeons will also use a combinations of the blunt dissection and sharp dissection techniques to create the pocket for the implant devices.
One of the major references describing breast surgery is AESTHETIC AND RECONSTRUCTIVE BREAST SURGERY, John Bostwick III, M.D., The C. V. Mosby Company 1983 which is extracted below to describe conventional methods in breast surgery. The reference is thoroughly illustrated for ease in following the text.
Innervation--Sensory nerves to the breast enter from the third to the sixth lateral intercostal nerves. These nerves pass through the interdigitations of the serratus anterior muscle. The second intercostal nerve, the intercostobrachial, goes across the axilla to the upper medial arm. It is usually divided during a mastectomy, resulting in anesthesia and paresthesia of the upper medial arm. It can also be damaged during axillary augmentation mammaplasty. Painful neuromas can occur when the lateral cutaneous nerves have been divided over the serrams anterior muscle during mastectomy. Resection of these neuromas and coverage with an implant or flap can give helpful improvement for these symptoms.
The upper portion of the breast and the infraclavicular skin are supplied by supraclavicular branches from the cervical plexus, which extend downward beneath the platysma muscle. This upper cervical plexus innervation should be remembered when a local block of the breast is performed. Anterior intercostal segmental nerves supply the medial breast and presternal area and enter with the internal thoracic perforators.
Innervation of the nipple-areola is primarily the fourth lateral intercostal branch. It enters laterally through the fourth interspace and runs medially under the deep fascia for a few centimeters. It then courses upward through the breast tissue to supply the nipple-areola. The third and fifth lateral nerves as well as the third through the fifth anterior intercostal nerves provide some sensation for the nipple-areola.
Lymphatics--The lymphatics of the breast originate throughout the gland about the lobules and the lactiferous ducts and communicate with the periarcolar lymphatic plexus. There are also direct lymphatic connections through the deep fascia into the underlying muscles. Primary lymph efferents pass from the upper outer quadrant of the breast, around the pectoralis major muscle, to the pectoral group of nodes. Some also pass directly to the subscapular nodes. The lymph then drains to the central nodes and next to the apical nodes of the axilla. The medial lymph channels accompany the internal thoracic perforators and drain to the parasternal nodes. These medial lymph nodes receive some lymph from the entire gland.
Placement of incisions--The primary consideration for breast augmentation is enlargement of the breasts to a size, contour, and form that is symmetrical and acceptable to the patient. Most patients are not concerned with incisions when the erythema fades, particularly If the breasts are soft and attractive. Selection of incision location must be individualized. Three incisions often used for breast augmentation are the inframammary, periareolar, and axillary.
Implant position--Implant position is a key factor in obtaining an excellent result from augmentation mammaplasty. When operations for breast enlargement were first developed, implants were placed over the chest wall musculature. This seemed to be the natural position to enlarge breast size. With this retromammary position there was and continues to be a high incidence of capsular contracture around the implant. This condition has developed despite the use of different implants, varied incisions, larger pockets, intraoperative antibiotics, and postoperative massage.
Placement of an implant in the submusculofascial position has resulted in a higher incidence of acceptably soft breasts for my patients. The implant is beneath the pectoralis major muscle and portions of the serratus anterior, rectus abdominis, and external oblique fasciae. The submusculofascial implant position gives an attractive augmentation and does not cause functional impairment.
This inframammary approach gives direct access to the submusculofascial position for breast augmentation. There is minimal disturbance of breast tissue with this approach.
Surgical approach and techniques--Accurate preoperative markings are an essential part of any breast operation. The patient should be upright when the drawings are made. The extent of the undermining for the pocket is marked above, usually to the second rib, laterally to the midaxillary line, and medically to the medial extent of the pectoralis major origins but not to the midline.
The inframammary crease dissection line is determined. If the breast is quite small and the distance from the lower areola to the inframammary crease is less than 5 cm, the inframammary crease must be lowered to 5 to 6 cm below the areola and the pocket dissected downward. If the inframammary crease is positioned properly, the pocket goes 1 cm below this crease.
A blunt subpectoral dissector or large urethral sound (size 26 French) is used to detach the pectoral muscle bluntly from the sternum and from its lower costal origins. It is essential that the lower pectoralis major fibers be divided and a pocket created sufficiently low beneath the musculofascial layer otherwise the implant position will be too high.
It is more difficult to create a symmetrical pocket from the axillary approach. Time spent achieving symmetry is essential. Most postoperative disappointments following this approach result from failure to create a low enough pocket and failure to develop symmetrical pockets.
Submammary augmentation--When the submammary implant position is chosen, the same periareolar, inframammary, or axillary incisions can be used to approach the retromammary space. The markings are the same as for submusculofascial breast augmentation. Elevation of the breast then proceeds above the musculofascial layer with primarily blunt dissection. Hemostasis in this plane between the superficial and deep fasciae must be exacting. Fiberoptic lights and a headlight are helpful. In the author's experience, hematomas occur more frequently with submammary augmentation than with the submuscular approach.
The pocket is irrigated to remove all loose material such as clots or fatty globules. Preplaced sutures are used before implant positioning. A retromammary pocket is developed through an inframammary incision. After adequate hemostasis is ensured, the silicone breast implant is inserted. Preplaced sutures are helpful to protect the implant from damage by a needle.
Periareolar approach--A periareolar incision is made, and the superficial dissection is made toward the inframammary crease. The breast parenchyma is retracted superiorly, and the retromammary pocket is dissected over the deep fascia. The silicone breast implant is then positioned in the submammary pocket, and the wound is closed in layers.
The periareolarapproach gives adequate access for submusculofascial dissection. However, some breast tissue must be divided with this technique. The line of incision requires minimal disturbance of breast tissue.
Objections to breast surgery--For some time, there have been objections raised to cosmetic breast surgery for a variety of reason. One such objection is that the scars from the operation are difficult to hide and the augmentation of the breast is sometimes accompanied by undesired scar tissue. In addition, the FDA has recently placed a temporary hold on the marketing of silicone filled breast implants because of doubts about their safety. Consequently, there has been a need for safer implants and an even greater need for a surgical procedure which minimizes or conceals scarring.
A number of U.S. patents illustrate the state of the art on instruments used in endoscopic surgery:
Wappler U.S. Pat. No. 1,880,551 shows a surgical endoscope. PA1 Yoon U.S. Pat. No. 4,254,762 shows a safety surgical endoscope. PA1 Santangelo U.S. Pat. No. 4,610,242 shows a surgical endoscope and surgical knife therein. PA1 Storz U.S. Pat. No. 4,656,999 shows a surgical endoscope with surgical blade moved by a scissors type operator. PA1 Nicholson U.S. Pat. No. 4,497,320 describes a cutting surgical knife for arthroscopic surgery. PA1 Lichtman U.S. Pat. Des. No. 286,438 shows a design for a surgical obturator. PA1 Johnson U.S. Pat. No. 5,250,072, of which this application is a continuation-in-part, discloses an endoscopic assisted breast augmentation mammoplasty.